Neurosurgical management in children with bleeding diathesis: auditing neurological outcome

Intelligence and executive function are associated with age at insult, time post-insult, and disability following chronic pediatric acquired brain injury

Background

Pediatric acquired brain injury (pABI) profoundly affects cognitive functions, encompassing IQ and executive functions (EFs). Particularly, young age at insult may lead to persistent and debilitating deficits, affecting daily-life functioning negatively. This study delves into the intricate interplay of age at insult, time post-insult, and their associations with IQ and EFs during chronic (>1 year) pABI. Additionally, we investigate cognitive performance across different levels of global function, recognizing the multifaceted nature of developmental factors influencing outcomes.

Methods

Drawing upon insult data and baseline information analyzing secondary outcomes from a multicenter RCT, including comprehensive medical and neuropsychological assessments of participants aged 10 to 17 years with pABI and parent-reported executive dysfunctions. The study examined associations between age at insult (early, EI; ≤7y vs. late, LI; > 7y) and time post-insult with IQ and EFs (updating, shifting, inhibition, and executive attention). Additionally, utilizing the Pediatric Glasgow Outcome Scale-Extended, we explored cognitive performance across levels of global functioning.

Results

Seventy-six participants, median 8 years at insult and 5 years post-insult, predominantly exhibiting moderate disability (n = 38), were included. Notably, participants with LI demonstrated superior IQ, executive attention, and shifting compared to EI, [adjusted mean differences with 95% Confidence Intervals (CIs); 7.9 (1.4, 14.4), 2.48 (0.71, 4.24) and 1.73 (0.03, 3.43), respectively]. Conversely, extended post-insult duration was associated with diminished performances, evident in mean differences with 95% CIs for IQ, updating, shifting, and executive attention compared to 1-2 years post-insult [-11.1 (-20.4, -1.7), -8.4 (-16.7, -0.1), -2.6 (-4.4, -0.7), -2.9 (-4.5, -1.2), -3.8 (-6.4, -1.3), -2.6 (-5.0, -0.3), and -3.2 (-5.7, -0.8)]. Global function exhibited a robust relationship with IQ and EFs.

Conclusion

Early insults and prolonged post-insult durations impose lasting tribulations in chronic pABI. While confirmation through larger studies is needed, these findings carry clinical implications, underscoring the importance of vigilance regarding early insults. Moreover, they dispel the notion that children fully recover from pABI; instead, they advocate equitable rehabilitation offerings for pABI, tailored to address cognitive functions, recognizing their pivotal role in achieving independence and participation in society. Incorporating disability screening in long-term follow-up assessments may prove beneficial.

Drug-resistant epilepsy in children with hemophilia: how can we do it surgically?

BACKGROUND

Drug-resistant epilepsy can occur in patients with intracranial hemorrhage (ICH) caused by hemophilia, there is a paucity of literature reporting the surgical treatment of these patients because of the high risk of bleeding and comprehensive management such as factor replacement during the period of perioperation.

METHODS

The data of 216 children with drug-resistant epilepsy who underwent surgically treatment in the Pediatric Epilepsy Center of the Capital Institute of Paediatrics were retrospectively reviewed. Seizure response and procedure complications were evaluated. Two cases children with hemophilia underwent surgical treatment at 29 months (case 1) and 6 years of age (case 2) were identified and followed up.

RESULTS

Both children have achieved seizure free without complications such as bleeding or infection after 28 months (case 1) and 21 months (case 2) follow-up.

CONCLUSION

For children with drug-resistant epilepsy associated with hemophilia, surgery that meets certain conditions can improve the prognosis safely and effectively.

Factors Associated with Nontraumatic Spontaneous Subdural Hematomas in Pediatric Patients

OBJECTIVE

 In our study, we aimed to summarize the etiology of subdural hematoma that was not traumatic and required operation in pediatric patients. The subdural hematoma characteristics, possible etiologies, and treatment, as well as the patient outcomes, were analyzed.

METHODS

 A retrospective examination was made of pediatric patients with subdural hematoma who were operated on at Ümraniye Training and Research Hospital. Patients with a history of trauma were excluded. Data on patient sex, age, bleeding location, type of hematoma based on computed tomography imaging, surgical treatment, presenting symptoms, presence of comorbidities, Glasgow Coma Scale, thrombocyte counts, and international normalized ratio values were recorded.

RESULTS

 Of the 19 patients included in the study, 4 were female and 15 were male. Their ages ranged between 0 and 15 (mean = 5.84) years. In 57.8% of the patients, comorbidities, including acute myeloid leukemia, a history of shunt operation, epilepsy, mucopolysaccharidosis, known subdural effusion, autism, coagulopathy, ventricular septal defect/tetralogy of Fallot, cerebrospinal fluid leakage after baclofen pump administration, Marfan's syndrome, and late neonatal sepsis were present, while 21% had arachnoid cysts and 21% had no reported comorbidities.

CONCLUSION

 This study suggests that, in pediatric patients with subdural hematoma with an amount of bleeding requiring surgical management, any underlying comorbidities should be investigated regardless of the presence of a history of trauma. While investigating systemic diseases, special attention should be paid to the presence of arachnoid cysts or disruption in cerebrospinal fluid dynamics along with a history of hematologic diseases.

Management of intracranial hemorrhage in hemophilia A patients

INTRODUCTION

Intracranial hemorrhage due to head trauma in patients with hemophilia is a major cause of mortality and morbidity. The incidence of central nervous system bleeding in these patients is between 3 and 8%. In this study, we shared our experience on the treatment and follow-up of seven pediatric patients with hemophilia A who had intracranial bleeding due to trauma.

MATERIALS AND METHODS

Between 2010 and 2019, the clinical and radiological findings of seven pediatric patients with hemophilia A with intracranial hemorrhage were retrospectively evaluated in our clinic. One patient underwent operation owing to intracranial hemorrhage, and the other six underwent conservative treatment. Hemoglobin, aPTT (activated partial thromboplastin time), and factor VIII levels were measured at regular intervals. For intracranial hemorrhage follow-up, regular computed tomography (CT) was performed.

RESULTS

All patients visited the emergency department with initial neurological complaints. Further, two of the seven patients died, one was treated with sequelae (cerebral palsy), and the other four were treated without sequelae.

CONCLUSIONS

Early diagnosis and treatment of intracranial hemorrhage is very important in patients with bleeding disorders. Factor VIII replacement should be performed in such patients prior to radiological examinations and consultations. The main objective should be to bring factor VIII levels to normal limits during their treatment and follow-up.

Management of hydrocephalus in infants with severe hemophilia A: report of 2 cases

The authors report on the clinical course of two infants with severe hemophilia A (HA) and concomitant progressive hydrocephalus that required management with a ventriculoperitoneal shunt. The first child, with known HA, presented with a spontaneous intracranial hemorrhage and acquired hydrocephalus. He underwent cerebrospinal fluid diversion with a temporary external ventricular drain, followed by placement of a ventriculoperitoneal shunt. The second child had hydrocephalus secondary to a Dandy-Walker malformation and was diagnosed with severe HA during preoperative evaluation. He underwent placement of a ventriculoperitoneal shunt after progression of the hydrocephalus. The authors also review the treatment of hydrocephalus in patients with HA and describe the perioperative protocols used in their two cases. Treatment of hydrocephalus in infants with HA requires unique perioperative management to avoid complications.